Dual antiplatelet therapy versus monotherapy after surgical intervention for chronic limb-threatening ischemia: Systematic review and meta-analysis with endovascular subanalysis.

Abstract

We compared the safety and efficacy of dual antiplatelet therapy (DAPT) vs monoantiplatelet therapy (MAPT) in patients with chronic limb-threatening ischemia undergoing open and/or endovascular surgery. Article screening was conducted using Medline, Embase, and the Cochrane databases. The outcomes analyzed included major bleeding, major amputation, major adverse limb events, amputation-free survival, reintervention, and mortality. A subanalysis was performed, which included only patients who underwent endovascular surgery. Additionally, a subgroup analysis was conducted to differentiate between target lesion reinterventions and interventions in other vessels. Statistical analysis was performed using the RStudio software. Study heterogeneity was assessed using the I² statistic. Seven studies with a total of 53,907 patients were included. Six observational studies and one randomized controlled trial were selected. Three studies used the same registry but were not included in the same analysis. DAPT was associated with a significant decrease in the risk of major amputation in both overall analysis (risk ratio [RR], 0.82; 95% confidence interval [CI], 0.75-0.89; P < .001; I² = 0%) and endovascular subanalysis (RR, 0.83; 95% CI, 0.73-0.93; P = .002; I² = 0%). However, DAPT was associated with an increased risk of major adverse limb events (RR, 1.10; 95% CI, 1.03-1.18; P = .007) and any vessel reintervention (RR, 1.07; 95% CI, 1.03-1.10; P < .001; I² = 0%). No significant differences were observed between DAPT and MAPT in either the overall or endovascular analyses regarding mortality, major bleeding, target lesion reintervention, or amputation-free survival. These findings suggest that using DAPT in patients with critical limb-threatening ischemia has the potential to decrease the number of amputations when compared with MAPT. However, DAPT may increase the likelihood of major adverse events and the need for any vessel reintervention. No statistically significant differences were identified between DAPT and MAPT for the outcomes of mortality, survival, major bleeding, or target lesion reintervention.